M75.41 identifies subacromial (shoulder) impingement syndrome specifically affecting the right shoulder — the mechanical compression of rotator cuff tendons and bursa beneath the acromion during arm elevation.

Documentation tips

What should appear in the chart to support M75.41.

Source · Editorial brief grounded in 5 cited references ↓

• Specify laterality by name ('right shoulder') — do not rely on operative-side stickers or unmarked diagrams to establish laterality for coding purposes.
• Record positive provocative test findings by name: Neer sign, Hawkins-Kennedy test, or painful arc — these directly support impingement syndrome over a generic pain code.
• Summarize imaging results that corroborate impingement: MRI findings of subacromial space narrowing, bursal thickening, or tendon signal change; X-ray findings of acromial spurring or type II/III acromion morphology.
• Document the functional impact (e.g., 'unable to reach overhead, limited to 90° active abduction') to establish medical necessity for physical therapy, injection, or surgical referral.
• If conservative treatment has been attempted, list modalities and duration (e.g., 'six weeks of physical therapy without adequate relief') — this supports medical necessity for subacromial injection (20610) or surgical decompression (29826).
• When co-existing pathology is present (bicipital tendinitis M75.21, calcific tendinitis M75.31, partial rotator cuff tear M75.111), document and code each condition separately rather than collapsing them under impingement.

Related CPT procedures

Procedure codes commonly billed with M75.41. Linking the right diagnosis to the right procedure is what establishes medical necessity.

Source · CMS LCDs · AAOS specialty guidance · claims-pattern analysis

Common coding pitfalls

The recurring mistakes coders make with M75.41 and adjacent codes.

Source · Editorial brief grounded in CDC ICD-10-CM tabular guidance, AAOS coding references, and cited references ↓

• Assigning M75.41 when only shoulder pain is documented — pain without a confirmed impingement diagnosis belongs at M25.511; upgrade to M75.41 only when the provider states the diagnosis.
• Using M75.41 alone when a concurrent rotator cuff tear is documented — impingement does not encode the tear; code both M75.41 and the applicable M75.1x tear code.
• Defaulting to M75.40 (unspecified) when the note clearly states 'right shoulder' — unspecified codes audit-flag as lacking specificity and can trigger payer downcoding or denial.
• Coding M75.41 for a traumatic impingement scenario — if the mechanism is acute trauma, evaluate whether an S-code (e.g., S40.011A for right shoulder contusion) is more appropriate and whether the impingement is a sequela.
• Pairing M25.511 (right shoulder pain) with M75.41 on the same claim — once impingement is established, the pain code is redundant and should be dropped per ICD-10-CM coding guidelines.

Clinical context

Source · Editorial summary grounded in 5 cited references ↓

Sibling codes

Other billable codes under M75.4 (laterality / anatomic variants).